D. A. R. P.
Vital signs, lab results, resident behavior.
What is Objective DATA?
Personal opinions and judgement.
What needs to be left out of nursing documentation?
A resident states, "I can't catch my breath" or rates their pain as a 5 on a scale from 0 to 10.
What is Subjective DATA?
Resident positioned in high Fowler's position.
What is a nursing ACTION/intervention?
This information describes the "situation"...
What are Subjective and Objective DATA?
Repositioning a resident, administering oxygen or medication per MD orders, discharge teaching...
What are nursing ACTIONs/interventions?
Resident's respiratory rate has decreased to 16 and effort is now unlabored.
What is a resident's RESPONSE/outcome?
In your nursing note, this information informs the health care team what was done for the resident...
What nursing ACTIONs/interventions were done for the resident?
Resident states " I can breathe easier now" or resident states their pain level has increased to an 8 out of 10.
What is a resident’s RESPONSE?
V/S: BP 148/86, P 78, RR 22, Temp 36.9
What is Objective DATA
Objective and subjective data collected AFTER nursing interventions and orders are carried out...
What was the resident RESPONSE/outcome?
DATA: subjective and objective
ACTION: nursing interventions
RESPONSE: resident response/outcome
PLAN: future nursing action
What is the nursing documentation format known as D.A.R.P. ?
Resident stated his pain has decreased to a 3 on a scale from 0 to 10.
What is a resident RESPONSE/outcome?